Download ID in the Elderly: GI,GU and Respiratory Infections

Infectious Disease in the
Elderly in Community and
Long Term Care Facilities
module 2
Respiratory diseases:
Pneumonia
Unit two
UNMC
Section of Infectious Diseases
Brandi L. Lesiak, PA-C, MPAS
Kim Meyer, PA-C, MPAS
Claudia Chaperon APRN, Phd
Ed Vandenberg MD CMD
Updated 11-23-06
PROCESS
A series of modules and questions
Step #1: Power-point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Objectives
Upon completion the learner will be able to:
1) Describe the age-related and diseaserelated predisposing factors of pneumonia
2) List interventions to prevent pneumonia
3) Describe diagnosis and treatment for
pneumonia in the elderly
Bacterial pneumonia (1, 2, 3)



Pneumonia is the leading infectious cause
of death in the USA and the world
Common source of morbidity and
mortality in older adults
Broadly classified into
Altered host defenses
 Increased exposure to bacteria

Pulmonary System:
Why pneumonia is so common in old
age?
Reduced barrier function of
Respiratory tracts due to:
 Altered mucous increases
bacterial adherence
 Altered respiratory cilia
function (slower/less
organized)
Leads to;
 Greater colonization with
Gm neg. bacteria

Chest wall is less compliant

Dependent on abdominal
breathing for lung expansion
Lungs are more compliant
Leading to:
 Increase in residual volume
 Decline FEV1

% of Value at 20-25 years
FEV-1 Versus Age
100%
50%
25%
30
50
Age in Years
70
80
Why pneumonia is so common in old age?



Decline in PaO2
PaO2 = 100-(age/3)
By age 40 yrs, full expansion does not occur
supine
By age 65 yrs, full expansion does not occur
sitting
pO2 Lower Limit of Normal for Age
100
pO2 mmHg
90
80
70
60
AGE
20
40
60
Effect of Age on p02 Seated and Supine
80
Pulmonary System:(4, 5)





Why pneumonia is so common in old age?
Increased silent aspiration of gastric and
oropharyngeal contents
Decreased protective reflexes with disease
(CVAs, swallowing disorders.
Decreased clearance of aspirate
Increased GERD
Increased dental disease
PREVENTION
(6, 7, 8)
Improve host defenses:
 Pneumococcal vaccine
 Improve cough reflex ( especially during
sleep)

-avoid sedatives, hypnotics, narcotics
Reminders to: deep breath, increase upright
activity and incentive respirometers
PREVENTION- continued
(9, 10)
Improve host defenses:
 Improve clearance of secretions
-humidify,
-reduce drying ( meds: anticholinerigcs)
-mucolytics
- smoking cessation
PREVENTION- continued
( 11, 12, 13, 14)
Decrease exposure to bacteria.



Hand washing, contact precautions
Avoidance of antibiotics
Reduce frequency and severity of aspirations
 Control reflux: ( upright after meals)
 Avoid NG tubes
 Oral hygiene
 Screen for and treat dysphagia
(Speech therapy, diet consistency)
Bacterial pneumonia


(15)
Community Acquired Pneumonia ( CAP)
 S. pneumoniae is the most common cause
 Other caused H.flu, M. catarrhalis, viral, atypicals
Hospital-acquired pneumonia
 Gram-negative rods (Pseudomonas, Acinetobacter,
Enterobacter) followed by Staphylococcus aureus
and Legionella are more common
 Aspiration pneumonia -anaerobes
Pitfall: No specific etiologic organism can be
determined for 30 – 50% of patients
Medina-Wadpole AM, JAGS 47:1005-1015,1999
Bacterial pneumonia

Symptoms:







Exam findings:




Fever, chills
Mental status changes
Weakness, arthralgias, myalgias
Shortness of breath, tachycardia
Cough, sputum production
Pleurisy, tightness
Elevated temperature
Crackles/rales, dullness to percussion
Increased respiratory rate, retractions
Lab/xray:

Leukocytosis, increased PMNs, elevated temp, CXR findings,
decreased O2 sat
Typical/ lobar pneumonia
Atypical/interstitial pneumonia
Typical pneumonia
Atypical pneumonia
S. pneumoniae
H. influenzae
Legionella spp
S. aureus
M. Catarrhalis
Mycoplasma
Chlamydia
Viruses
Coxiella
Enterobacteriaceae
Pseudomonas
Older
Commorbidities frequent
Symptoms <1wk
URI symptoms infrequent
Unilobar segmental/lobar
infiltrates
Leukocytosis common
Younger
Comorbidities rare
Gradual onset
Symptoms>1wk
URI symptoms frequent
Multiple subsegmental infilt
Leukocytosis uncommon
Bacterial pneumonia

Sputum culture:



Should be <25 epi cells, moderate to many WBCs
Gram stain
Color or characteristic may aid in preliminary dx




(16)
Rusty colored: Strep pneumonia
Currant jelly: Klebsiella pneumonia
Blood tinged: Tuberculosis
Blood culture:

Many organisms can spread hematogenously, and blood
cultures should be obtained (i.e. Strep pneumonia,
Staph Aureus)
Aspiration Pneumonia (17, 18, 19, 20)






Aspiration of bacterial of oropharyngeal or gastric
secretions
Common in elderly population, especially with
altered mental status & dysphagia
Risk factor in both community and nosocomial
acquired pneumonia
Caused by mixed anaerobic flora and viridans
streptococci in community-acquired
Gram-negatives more important in nosocomial
aspiration penumonia
Dependant portions of the lung: superior segment
and RLL most common site
The End of Module Two
on
Respiratory infectious
diseases
in
the Elderly
Post-test
A 75-year-old man who had onset of temperatures
to 39°C (102.2°F), myalgia, fatigue, headache,
cough, and rhinorrhea 7 days ago has recurrence
of fever and worsening of cough. The fever,
myalgia, and headache gradually resolved over
the first four days but the respiratory symptoms
persisted. A radiograph of the chest shows a
right lower lobe pneumonia. Which of the
following organisms is the most likely cause of
the worsening symptoms?
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Which of the following organisms is the
most likely cause of the worsening
symptoms?
A.
B.
C.
D.
E.
Influenza virus
Klebsiella pneumoniae
Mycoplasma pneumoniae.
Staphylococcus aureus.
Streptococcus pneumoniae
Answer: E. Streptococcus pneumoniae

Pneumonia is the major complication of influenza and other
viral respiratory infections. Unlike other forms of influenzarelated pneumonia, the systemic symptoms of primary influenza
pneumonia do not resolve 2 to 4 days after onset of the illness,
and the patient is rapidly overcome by the viral illness.
Alternatively, influenza may be complicated by a bacterial
superinfection that often occurs 7 to 10 days after the onset of
symptoms. By this time in the course of the illness, there is a
relatively small viral load, but host defenses are decreased
because of damage caused to the respiratory epithelium by the
viral illness. This may result in a bacterial pneumonia. The most
frequently implicated bacterial agent responsible for bacterial
superinfections in this setting is Streptococcus pneumoniae.
Staphylococcus aureus, although reported in outbreaks during severe
influenza A seasons, is considerably less common than
Streptococcus pneumoniae. Mycoplasma pneumoniae is an uncommon
superinfecting organism. Gram-negative bacilli are common only
in patients who are either hospitalized or are residents of
chronic-care facilities.
end
Readings and resources
(1)Niederman MS. Nosocomial pneumonia in the elderly patient. Chronic care facility
and hospital considerations. Clin Chest Med 1993;14:479-490.
(2) Pennington JE. Respiratory tract infections: intrinsic risk factors. Am J Med
1994;76:34-41.
(3) Yamaya M, et. al. Interventions to prevent pneumonia among older adults.
JAGS 49:85-90, 2001
(4) Barish CF. Respiratory complications of gastroesophageal reflux. Arch Intern
Med 1985;145:1882-1888.
(5) Yamaya M, et. al. Interventions to prevent pneumonia among older adults.JAGS
49:85-90, 2001
(6) Sims RV, Steinmann WC, McConville JH et al. The clinical effectiveness of
pneumococcal vaccine in the elderly.Ann Intern Med. 1988 May;108(5):653-7.
Erratum in: Ann Intern Med 1988 Nov 1;109(9):762-3.
(7) Terpenning MS. et al..Aspiration pneumonia: dental and oral risk factors in an
older veteran population. J Am Geriatr Soc. 2001 May;49(5):557-63.
(8) Yoneyama T,et. al. Oral care and pneumonia. Oral Care Working Group.
Lancet. 1999 Aug 7;354(9177):515.
(9) Huxley EJ, Viroslav J, Gray WR Pharyngeal aspiration in normal adults and
patients with depressed consciousness. Am J Med. 1978 Apr;64(4):564-8.
(10) Sims RV, Steinmann WC, McConville JH The clinical effectiveness of
pneumococcal vaccine in the elderly.
Ann Intern Med. 1988 May;108(5):653-7. Erratum in: Ann Intern Med 1988
Nov 1;109(9):762-3.
(11) Barish CF Respiratory complications of gastroesophageal reflux.
Arch Intern Med. 1985 Oct;145(10):1882-8. Review.
(12) Craven DE Preventing nosocomial pneumonia: state of the art and
perspectives for the 1990s. Am J Med. 1991 Sep 16;91(3B):44S-53S. Review
(13) Meguro K Prevention of respiratory infections in elderly bed-bound nursing
home patients.Tohoku J Exp Med. 1992 Jun;167(2):135-42.
(14) Barza M Effect of broad-spectrum parenteral antibiotics on "colonization
resistance" of intestinal microflora of humans. Antimicrob Agents
Chemother. 1987 May;31(5):723-7
(15) Hutt E. Evidence-based guidelines for management of nursing homeacquired pneumonia. J Fam Pract. 2002 Aug;51(8):709-16.
16) Medina-Walpole AM, Katz PR. Nursing home-acquired pneumonia. J Am
Geriatr Soc. 1999 Aug;47(8):1005-15. Review.
(17) Johanson WG. Aspiration pneumonia, anaerobic infections, and lung
abscess.Med Clin North Am. 1980 May;64(3):385-94. Review.
(18) Feinberg MJ, Aspiration and the elderly.
Dysphagia. 1990;5(2):61-71. Review.
(19) Kikuchi R, High incidence of silent aspiration in elderly patients with
community-acquired pneumonia.
Am J Respir Crit Care Med. 1994 Jul;150(1):251-3. .
(20) Johanson WG, Nosocomial respiratory infections with gram-negative bacilli.
The significance of colonization of the respiratory tract. Ann Intern Med.
1972 Nov;77(5):701-6. No abstract available